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HomeMy WebLinkAbout0009 SUNSET AVENUE - Health Centerville A = 226 • i :■� �■■■ ■r® ®■ri1N■■■■MO■M■■OEM■ ■o■M■■E■■EM■■■1 A�■■E■■■■■a■■■■MM■■■■■■■■■M■■■■■■■■■■■■■■■■OMEN ■ ■■■■■■ ■ ■■■■■■■■■�■■■■■���■■■■■�■■ ■�■■ME■■ I■■■■■■■■■M■■■■■■■■■■■�■■v■■ v■■■�■ �■■■■■■■■■ I■■■i■■ ■■ ■■■■■■■■■■■�■�■ ■�■�■■■■■w�■�■■■■�■v i■■■■■■■MM■■■■■■■■■■■MM■■o■■E■■■■■■■■■■■M■■MMM■i ■■■■■■■■■■■■■■■a■■■��■■■■��■ �■■��■�■��■s■■■■ ■■■■■■■■■■■■■■■■■■■■■■M■■■■■■■■■■■■■■■■■■■■E 1■■����■■��■ ■ ■■ ■l i�:�.Ll �.LLr■■�■■■■■■■■■■ MO■■E■ IMMENSE i■■■■■■■■■■■■■■■■■■ mmimm-z-�■■■■■■■■MEMO■■����� 11M■■■■■■■■■■■■■■■■■■ ■■■■■�■■��■■■■■■■�■ �■��� � EMMEMMEMMEMEMEME 1■■M■■■■■■ M■■■■EM■M■E■ MEM■EMEME■ ME■■M■■■MME INN MEMEMES, INN MENEM 1■ ■■ ■■ME■■■■■EM ■■■■E■M■■E■ ■■■M■■■E■E■■E MEN INN ME■N■■ MENEM ■■ ■■���■■■■�����■■■ ■■■■■�■�■�■■ EMONOMMEMEMEMEMEME NEW 1"1.mmmmmmmmmmmmmmIMMEMMEMMEMEMEME ��■■■■■■■■■■■■■■■■■■■■■■■■mom■■■■■■■■■■MMMmMMmM1 IMMEMEMEMMEM IMMEMEMMEMEMEMEMEM 7■■■■ ■��■��■■■■■■■■■■■■■■■■ ■/ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 I M yy< 7-9-Sunset Avenue Un Property Address Baccari Owner. Owners Name information is required for every Centerville l/ Ma 12-6-16 :r-k page. Cityrrown State Zip Code Date of Ins P ion Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. Company Name P.O.Box 151 Company Address Forestdale Ma 02644 Cityrrown State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12-6-16 Inspecto;e/m Si ure Date The sy inspector all submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)w' in 30 days of completing this inspection. If the system is a shared system or has a design flow of Ot)0_gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: El One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y . 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System-Page 3 of 17 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: seasonal Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail:. Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3h3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner pumps for maintenance Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1990 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 8,1 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 1" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1' Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludgejudge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. to protect leaching Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M yy< 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): nosigns of cracks or leaks. no concrete decay. Baffles in place Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no cracks or leaks Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): small pump chamber. pump is working with high water audio alarm in house works tested. pump has weeping hole to drain line *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: infultrators dry at time of inspection. no high staining to indicate past failure. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: 6 infultrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no signs of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool. Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ''< 7-9-Sunset Avenue Property Address Baccad Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I � 2 �0 3, c 4 61 3 � � I a3 'S9 3 a (o 3 3e y 3 Lt � V2 S S� � 33 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4.5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: town gis maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: hand dug test hole 10'from leaching area G/W was at 42"at time of inspection. bottom of infultrators are at 24" below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7-9-Sunset Avenue Property Address Baccari Owner Owner's Name information is required for every Centerville Ma 12-6-16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION �/9 p / SEWAGE # VILLAGE ! ASSESSOR'S MAP & LOT •f INSTALLER'S NAME PHONE NO.J,P AOM, ,ep,,5 Son SEPTIC TANK CAPACITY I w- LEACHING FACILITY (type _ „ ,".. ,.. •. _ u x.. NO. OF BEDROOMS PRIVATE WELL OR PUBLIC,7WATER • BUILDER OR OWNER! . P DATE PERMIT ISS�D: DATE COMPLIANCE.ISSUED:_Q VARIANCE GRANTED: Yes No h / c. ' Q ' I J0 Commonwealth of Massachusetts RECEIVED Q Executive Office of Environmental Affairs ��N 2 s 1997 Department of Environmental Protection Wllllam F.Weld 7Tr e Gwwrwr Argeo Paul CMluccl hs U.Gowmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A V CERTIFICATION propertyAddrm&. —�— '9 Sunset , Centerville AddressofOwner. Charles Pisacano Date of Inspection: (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: i✓Passea _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails / Inspector's Signature: `�'(/ /�% "'"'-"^ Date: /y-A �,— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] SYSTEM PASSES: Y I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: J(revil/03/95) or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes ection. no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. 1 One WlnUw Street a Boston,Massachusetts 02108 a FAX(617)SW1049 is Telephone(617)292-SM iJ Printed on Recycled Paper 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddmm 7 & 9 Sunset Lane, Centerville Owner. Charles Pisacano Date of Inspection: B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address; 7 & 9 Sunset Ln, Centerville Owner. Charles Pisacano Date of Inspection: o 9 D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] GE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The o r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requiremgtsof 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised ll/03/95) 3 .I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddrew 7 & 9 Sunset Ln, Centerville Owner. Charles Pisacano Date of InspeaUon: Check if the following have been done. 2Pumping information was requested of the owner,occupant,and Board of Health. —LAone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ..l:CAs built plans have been obtained and examined. Note if they are not available with N/A. jZe facility or dwelling was inspected for signs of sewage back-up. system does not receive non-sanitary or industrial waste flow _Vke site was inspected for signs of breakout. system components, excluding the Soil Absorption System, have been located on the site. ,�e septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of bales or tees,,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. /The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C SYSTEM INFORMATION Property Address: 7 & 9 Sunset Ln, Centerville Owner. Charles Pisacano Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Derr flow:�one Number of bedrooms: Number of current residents: Garbage grinder(yes or no):_.&0 Laundry connected to system(yes or no):/,r 6 Seasonal use(yes or no): Water meter readings,if available: _ 1 9 9 5 — 68 , 000 gals. 1996 - 64 , 000 gait _ Last date of occupancy:- COMMERCIALANDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Lest date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS d source of information: 14, 'd System ped as part of inspection: (yes or no)_ If yes,'volume pumped: gallons Reason for pumping: TYPE,. 0 YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: J2 s 6 r V Sewage odors detected when arriving at the site: (yes or no) A-� (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 & 9 Sunset Ln, Centerville Owner. Charles Pisacano Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: / Material of construction: _metal_FRP_other(e:plain) 4 1 Dimensions: Shulge depth: J e , Distance from top of sludge to bottom of outlet tee or baffle:1) b 1 � Scum thickness:_ D ) Distance from top of scum to top of outlet tee or baffle:_3 ` Distance from bottom of scum to bottom of outlet tee or baffle: I / Comments: (recommendation for pumping,condition of' t and outlet tees o baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) a c!, >+, v Gl= TRAP._ (locate on 'te plan) Depth belo grade: Material o construction:_concrete_metal_FRP_other(ezplain) Dimensions: Scum Distance from p of scum to top of outlet tee or baffle: Distance from m of scum to bottom of outlet tee or baffle: Comments: (recommends on for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of le ,etc.) n (revised 11/03/95) 6 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddrese: 7 & 9 Sunset Ln, Centerville Owner. Charles Risacano Date of Inspection: �. �/•� . TIG OR HOLDING TANK_ (locate site plan) Depth grade: Material constiaction•_concrete_metal_FRP_other(explam) Capam gallons Design ow: gallons/day Alarm 1 1: Commen (couditio of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: V (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER. (locate on site plan) Pumps in working order:(yes or no) + L`5 Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) c' o (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addreaw 7 & 9 Sunset Ln, Centerville owner. Charles Pisacano Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on sits plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: leaching pits,number:_ leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number: ® _ m Comments:(cote condition o sorl s' of hydraulic fed�lure, level of ponding getation,etcJ �, B cl 6 ti w y condit�' n of ve _._� !J4/ 1"J � 1 f�A�®•�" S to Ja- L v0e r ���/ C OA _ (locate n site plan) kowum configuration: liquid to inlet invert: s layer. layer: f cesspool: onstr u tion: groundwater: (cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.) PRIVY: (locate jonte plan) Materi oonatructioa: Dimensions:Depth ids• Commenote condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) g 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Add+ees: 7 & 9 Sunset Ln, Centerville Owner. Charles Pisacano Date of Inspeotion: G �, e ey SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks r locate all wells within 100' 2 ' 30 3 DEPTH TO GROUNDWATER Depth to groundwater. S" feet � method of determination or approximation: 13 0 G<d r (revised 11/03/95) 9 o TOWN OF BARNSTABLE LOCATION ?��j ��� �.� �,/ SEWAGE # - VILLAGE��',I l ; ( , ' ASSESSOR'S MAP & LOIV INSTALLER'S NAME & PHONE No. T,-P hnAcom�'GQ2.S Sorg SEPTIC TANK CAPACITY LEACHING FACILITY:(type) )1_ Q}gsize) NO. OF BEDROOM& PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER - - DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: - l(© - `-1 VARIANCE GRANTED: Yes No i 20, I4t r —2 S No. .� Flcs....$.... 3,0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphratiun for Dinpuml Workii Cnunutrur#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair JX)� an Individual Sewage Disposal System at: 7&9 Sunset Ave Craigville . ....-•--•-..._.•..-----...-•-----•---•. ................................................................................................. P Location-Address or Lot No. �x:X:y•-•-------------•----•--------------•--•-••--•--------•--•---••••••------------..... ---•-••-•----------•-------•----••------•--------•.-..-----•-----•-•---•-----------------......••. Owner Address .Macomber...Jr- -------------•-------------------------------•-••------ ---------------......----------••---•----••-•--------•--•--------------------•-•-------••-•------ Installer Address UType of Building Size Lot............................Sq. feet ., Dwelling}- No. of Bedrooms............4------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons------------------------.... Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------- ------ ----------------------------------- ---------•-----•-------•--•---•-----•-----•-•----------•----. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter....------------ Depth.............. x Disposal Trench2-NoA................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet----..--.--......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit......--.----------- Depth to ground water...--................... fi Test Pit No. 2.........>......minutes per inch Depth of Test Pit.................... Depth to ground water..............--........ P+ --------------------------------------------------=.......................................................................................................... ODescription of Soil..........................................Sand.................................................................................................................. x U ------•-•--•----•-•-----•-•------------•-----------•---•-----------•---••--••-•••--------------------•-----------------------------•---•----------------••-------------•-----•........-----••••-•••••••. W U Nature of Repairs or Alterations=Answer when applicable----Z_-sel? - - --,dank---pump-,chamber................... A....inf il.txat•oxs. Cmi.t---ces.s.pAmis.-................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be is ed y the bo d o health. Signed ... - �..... 81.$.�9 4.......:...... Application Approved By . ......... .. ... -: _............ ..�� .. . : . ..................................... ---- - ------------------ Dare Application Disapproved for the following reasons: .................................................... ............................................... . .................... .... ........................ ................................ ........ . . ......... ---- Dare Permit No. k................. _ �S9 .... Issued . ............................... . . ...... Dam ....._�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Bi-ynittl nrlkri Tomitrurtiinn Vrrm' it Application is hereby made for a Permit to Construct ( ) or Repair kX)j an Individual Sewage Disposal System at: 7&9 Sunset Ave Craigville •-----------------•-•-•-•--•-•-••-•- -•-••----•--•••---••----•••-•-•--••---.....----------•--•-----•--••---•-•--•---.......•--•....---- Locatiou-Address or Lot No. PerrY._.......... Owner . Address aJ.TP.Macomber Jr:.---•--•--••••-•••••-•--•---------------•-•-------•-•-- ••-----•---•----------------------------------•--------•--•-..................................... Installer Address UType of Building Size Lot............................Sq. feet ,., Dwellings No. of Bedrooms------------A____________________---------Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons.......--------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- -- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length------_............. Total leaching area....................sq. ft. Seepage Pit No-----------__...... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------------ •--•------------•---...--•••-•--•---•------ Date------------------------------....----- � Test Pit No. I................minutes per inch Depth of Test Pit---_-.--__________.. Depth to ground water------------------------ f4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 04 ----•-••••------------------•............---------------•----.......----••------•-•---------.........................................._...--------•---..---• D Description of Soil---------------------------------------- Sat1d.. W U ---------•----•-•-••...••••---------•-••-•••---•••--•--•-••••-••-------------•-----••--••••••••-------•-•-•-•-----------•-•••------------------•-•••----••-•-•------••-•-•••-•--•••............--.•-•--- W UNature of Repairs or Alterations—Answer when applicable._-_1_-septic--_tank Dump chamber A....tuf 1.1 t.ra.t.ox.,9 0xi t---ce_s.s.T)0.01s--------------•••----------------•----------••------••--•----•---------------------••--•••......---.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued/by the board o health. Signed .......... . a 1 1: �2��'�s =' -----8 8.1....... ........ C a, `f Application Approved Bye-------------- .._..:. - /� � ................. Date Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------ 19 7 q Date PermitNo. .................................................................... Issued .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C11Er#ifi atro of C�oxaplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by J .P.Macomber Jr . Instal ler at .7$.9....Sunset Ave...Craigville - ------------------ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. y y -: L/5..�� dated e�>.. �` j THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... ............_l� .....)4 ... .t... Inspector -- ---------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �'� TOWN OF BARNSTABLE No..._..--•...............� FEE... 14spsal Workii (fnnitritrtinrt hermit J P.Macomber Jr. Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair (X)) an Individual Sewage Disposal System && 7&9 Sunset Ave Craigville atNo. . ..................................................... --.....--------------------...------------------------------•---•••....--••- Street r-. ` as shown on the application for Disposal Works Construction Permit No..................... Dated c p/-lJ.....'" .• Board of Health DATE............ �s --------------------------------------- FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS